Tuesday, 7 March 2017

Paying Claims Outside of the MCE

All institutional inpatient claims are routed through the MCE before they are processed to payment. There may be special circumstances, however, when it is necessary to pay claims bypassing MCE edits. The CMS will notify the contractor of these instances. They include:

• New coverage policies are enacted by Congress with effective dates that preclude making the necessary changes timely; and 
• Errors are discovered that cannot be corrected timely. 

A/B MACs (A) are responsible for reporting problems timely. 

Requesting to Pay Claims Without MCE Approval

The contractor may also request approval from the RO in specific situations to pay claims without first sending them through the MCE. 
Examples of such situations are: 
• A systems error cannot be corrected timely, and the provider's cash flow will be substantially impacted; and/or 
• Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions in particular cases may necessitate that payment be made outside the normal process.

Procedures for Paying Claims Without Passing through the MCE (Rev. 2117, Issued: 12-10-10, Effective: 01-12-11, Implementation: 01-12-11)

Before an inpatient claim may be paid without first going through the MCE, the contractor shall obtain approval from CMS Central Office or the RO. 

Note: In certain situations, contractors bypass the MCE through an established, CMSinstructed claim processing procedure (e.g., to verify a facility is certified to perform a specified service after a MCE limited coverage edit is applied). Such scenarios do not require approval from the RO as the approval for such a bypass was inherently implied when the established procedure was first implemented.

 In all instances involving payment outside the normal inpatient editing process, the contractor applies the following procedures: 
• Contractors shall submit the claim overriding the MCE using the appropriate field in FISS. 
• Pay interest accrued through the date payment is made on clean claims. Do not pay any additional interest. 
• Maintain a record of payment and implement controls to be sure that incorrect payment is not made, i.e., when the claim is paid without being subject to normal editing. 
• Monitor MCE software to determine when the impediment to processing is removed. 
• Consider the claim processed for workload and expenditure reports when it is paid.
• Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month a report of all inpatient claims paid without processing through the MCE with the exception of override situations explained in the Note above (e.g., for limited coverage edits). The list of claims paid outside of the MCE is to include the following information:
o HIC 
o DCN 
o DOS (From/Through) 
o Provider Number 
o MCE/OCE OVR (Claim/Line)
o Reimbursement Amount 
o Receipt Date 
o Process Date 
o Paid Date

Also, include summary data for each edit code showing claim volume and payment. Any override approvals received and/or relevant JSM references should be annotated on the reports.

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